Start
heaf_16_fup3
Health & Employment After Fifty (HEAF Study): Follow-up Questionnaire
The answers given on this form are confidential. Replies will only been seen by a small medical research team
Section One: About Yourself and Your Work

Please fill in today’s date

Generic Date

Please fill in your date of birth

Date of birth

What is your current marital status? (Tick one box)

a
Married
b
Single
c
Civil partnership
d
Widowed
e
Divorced
f
Living with a partner
In an average week, roughly how many hours would you spend doing the following activities? (Please answer each question)
Hours per week
Hours in week
Working in a paid job (whether employed or self-employed)
Giving personal care to someone in your home or family
Working in an unpaid job for others outside your home and family (e.g. as a volunteer for a charity)
Doing hobbies
In an average week, and outside any paid jobs that you do, roughly how many hours would you spend doing the following activities? (Please answer each question)
Hours per week
Hours in week
Physical activities sufficient to make you hot or sweaty (e.g. heavy gardening, dancing, cycling, jogging)
Meeting or doing things with friends or relatives who do not live in your home

Which of the following best describes your present work situation? (Tick one box)

a
Employed
b
Self-employed
c
Unemployed
d
Retired
e
Employed off sick
f
Self-employed off sick

Has your employment position changed since we last contacted you about a year ago?

(Please tick the box that best applies to you and follow the instructions).

1
I did not have a paid job when you last contacted me, and I do not have a paid job now
2
I have the same main job as when you last contacted me
3
My employment position has changed since you last contacted me.
Questions 7 and 8 are only for people who are still in the same main job as when last contacted.
qc_6 == 2

Is your main job more or less the same as when we last contacted you (i.e. hours worked, tasks involved, support from managers and colleagues)?

a
No
b
Yes
If yes, please move on to Question 29 on page 5
If no, how has your job changed since we last contacted you?
qc_7 == a

How has it changed?

Generic text

Have you reduced or changed what you do at work because of a health problem? Please describe the health problems and any changes your employer may have made to help

1
No
2
Yes
Generic text
If you have answered questions 7 and 8 and are still in the same main job as when we last contacted you please go to Question 29 on page 5
If My employment position has changed since you last contacted me (Please skip the next two questions and go to Question 9 on page 2) to question 6
qc_6 == 3

In the time since we last contacted you, have you left the main job you were doing at that time?

1
No, I did not have a job when last contacted.
2
Yes
If Yes to question 9 (Please continue with Question 10)
qc_9 == 2

When did you leave the job?

Generic Date

Did you leave because of a health problem? (Tick one box)

a
No, not at all
b
Yes, a health problem was the main reason for leaving
c
Yes, a health problem was part of the reason for leaving
If there was a health problem,
qc_11 == b || qc_11 == c

what type of problem was it? (Tick all the boxes that apply)

a
A problem with your back, neck, arm, shoulder or leg
b
A mental health problem or stress
c
A problem with your heart or lungs
d
Another type of health problem
e
Not applicable, no health problem

Do you have a new paid job (whether employed or self-employed) since we last contacted you?

a
No
b
Yes
If Yes to question 13 (Please continue with Question 14)
qc_13 == b

What is your MAIN occupation at the moment? Occupation (e.g. secretary, teacher, builder)

Generic text

and in what industry do you work? Industry (e.g. farming, shipyard, car factory, shoe shop, hospital, insurance office)

Generic text

When did you start this job?

Generic Date

Is your contract of employment permanent or temporary/renewable?

a
Permanent
b
Temporary/renewable
c
Not applicable (self-employed)

Roughly how many people in total work for your employer?

(If self-employed, please indicate the number of people in total you employ)

a
Just you
b
2-9
c
10-29
d
30-499
e
500 or more

Does your main job involve rotating or variable shifts?

a
Often
b
Sometimes
c
Rarely/never

Does your main job involve night work (i.e. between 2.00 a.m. and 4.00 a.m.)?

a
Often
b
Sometimes
c
Rarely/never

Is driving part of your main job?

(Tick one box. NB This does not include travel to or from your main place of work )

a
Essential to the job
b
A part of the job, but not essential
c
No
In your main job, does an average day at work involve any of the following activities?

(Please tick yes or no for each activity)

-

1 - No

2 - Yes

Kneeling or squatting for longer than 1 hour per day in total
Climbing a ladder
Climbing up and down more than 30 flights of stairs per day
Digging or shovelling
Lifting weights of 10kg (25lbs) or more by hand
Standing or walking for most of the day
Standing or walking for more than 3 hours at a time
Hard physical work that makes you hot or sweaty

Ignoring overtime, does your main job give you a fixed salary, or are you paid according to your output (e.g. the number of tasks you do or things you make)? (Tick one box)

a
Fixed salary
b
Paid by output

In your main job, do you have a choice in deciding what you do, how you do things, or when you do things? (Tick one box)

a
Often
b
Sometimes
c
Rarely/never

Do you have a fixed time when you have to begin work? (Tick one box)

a
All work days
b
Most work days
c
Some work days
d
Never (I choose for myself)

How much holiday are you allowed from your job per year (including Bank Holidays)?a) ... Days or b) ... No fixed limit (Please tick)

(Answer a, or b)

Days in year
b
tick

How much holiday do you take each year in your job (including Bank Holidays)? ... days

Days in year

If you fell ill and were off work, how long could you get your normal full pay (excluding bonuses)? (Tick one box)

a
Less than one week
b
1 to 4 weeks
c
1 to 6 months
d
More than 6 months
e
Not sure

If you had a long-term health problem, might you qualify for an ill-health retirement pension (from your employer or insurance)? (Tick one box)

a
Yes
b
No
c
Don’t know
I did not have a paid job when you last contacted me, and I do not have a paid job now to question 6 or No to question 13 (Please go to Section 2 on page 7, starting at Question 46)
qc_6 == 1 || qc_13 == a
Else

Do you have a zero hours contract?

a
Yes
b
No

When you have difficulties at work, how often do you get help and support from your colleagues, supervisor or manager? (Tick one box)

a
Often
b
Sometimes
c
Rarely/never
d
Not applicable (work alone)

Do you ever lie awake at night worrying about work or angry about work? (Tick one box)

a
Often
b
Sometimes
c
Rarely/never

How satisfied are you with the amount you are paid in your job, all things considered?

(Tick one box)

a
Very satisfied
b
Satisfied/fairly satisfied
c
Dissatisfied
d
Very dissatisfied

How satisfied are you with your working hours and your work timetable (e.g. start and finish time), all things considered? (Tick one box)

a
Very satisfied
b
Satisfied/fairly satisfied
c
Dissatisfied
d
Very dissatisfied

Does your work give you a feeling of achievement? (Tick one box)

a
Often
b
Sometimes
c
Rarely/never

In your work, do you feel appreciated by others (managers, colleagues, customers etc)?

a
Often
b
Sometimes
c
Rarely/never

Do you have friends at work with whom you also spend time outside work? (Tick one box)

a
Yes
b
No

Is there anyone at work you find very difficult to get on with? (Tick one box)

a
Yes
b
No

Do you ever get criticised unfairly at work? (Tick one box)

a
Often
b
Sometimes
c
Rarely/never

How satisfied have you been with your job as a whole, taking everything into consideration?

(Tick one box)

a
Very satisfied
b
Satisfied/fairly satisfied
c
Dissatisfied
d
Very dissatisfied

Provided that you stay well, how secure do you feel your job is?

(Tick one box)

a
Very secure
b
Secure
c
Rather insecure
d
Very insecure

How secure do you feel your job would be if you had an illness that kept you off work for three months or more? (Tick one box)

a
Very secure
b
Secure
c
Rather insecure
d
Very insecure

Currently, how well do you cope with the physical demands of your job? (Tick one box)

a
Easily
b
Just about
c
With some difficulty
d
With great difficulty
e
Not coping

Currently, how well do you cope with the mental demands of your job? (Tick one box)

a
Easily
b
Just about
c
With some difficulty
d
With great difficulty
e
Not coping

Do you expect that you will still be able (physically and mentally) to carry out the same kind of work in two years time? (Tick one box)

a
Yes
b
No
c
Not sure

Does your job involve sitting for most of the day?

a
Yes
b
No
Section Two: Personal Finance

How well do you feel you are managing financially these days? (Tick the box that best applies)

a
Living comfortably
b
Doing alright
c
Just about getting by
d
Finding it difficult to make ends meet
e
Finding it very difficult to make ends meet

Are there things which you used to have, and which you would like to have now, but can no longer afford? (Tick one box)

a
No
b
A few things
c
Many things

Are there things which your friends or family have, that you would like to have but cannot afford? (Tick one box)

a
No
b
A few things
c
Many things
Have you ever received any of the following benefits? (Please tick all that apply)
-

1 - yes

Incapacity benefit
Invalidity benefit
Disability Living Allowance (DLA)
Severe Disablement Allowance
Personal Independence Payment (PIP)
Employment and Support Allowance (ESA)
None of the above
If yes,
qc_49_a-g$1;1 == 1 || qc_49_a-g$1;2 == 1 || qc_49_a-g$1;3 == 1 || qc_49_a-g$1;4 == 1 || qc_49_a-g$1;5 == 1 || qc_49_a-g$1;6 == 1

has a benefit ever been stopped as a result of an assessment? (Tick one box)

a
Yes
b
No
c
Not applicable
If yes,
qc_50 == a

when was this? (if more than one benefit has been stopped, please record the first time this happened)

Generic Date

Are you currently receiving an ill-health retirement pension?

a
No
b
Yes

If you are already fully retired, please tick this box and move to Section 3 on page 8, starting at Question 57.

1
tick
(Otherwise, please continue with question 54).
qc_53 != 1

At what age do you expect to retire fully? ... years old

Age

Do you expect to reduce your paid work before you retire fully? (e.g. by working shorter hours for less pay)? (Tick one box)

a
No
b
Yes
c
Not sure

In an ideal world, at what age would you like to retire fully? a) … years old

Age
1
or never
Section Three: Health

In general would you say your health is? (Tick one box)

a
Excellent
b
Very good
c
Good
d
Fair
e
Poor

How much of the following do you drink per week, on average? Beer, cider, lager ... Pints

How many

How much of the following do you drink per week, on average? Wine, sherry ... Glasses

How many

How much of the following do you drink per week, on average? Spirits, Liqueurs ... measures

How many

Please give your weight Weight ... st ... lbs or ... kg

Stones
Pounds in stone
Kilograms
Below are some statements about feelings and thoughts. Please tick the box in each row that best describes your experience of each over the last 2 weeks (One tick for each row)
-

1 - None of the time

2 - Rarely

3 - Some of the time

4 - Often

5 - All of the time

I’ve been feeling optimistic about the future
I’ve been feeling useful
I’ve been feeling relaxed
I’ve been feeling interested in other people
I’ve had energy to spare
I’ve been dealing with problems well
I’ve been thinking clearly
I’ve been feeling good about myself
I’ve been feeling close to other people
I’ve been feeling confident
I’ve been able to make up my own mind about things
I’ve been feeling loved
I’ve been interested in new things
I’ve been feeling cheerful

Which of the following best describes your walking speed? (Tick one box)

a
Unable to walk
b
Very slow
c
Stroll at an easy pace
d
Normal pace
e
Fairly brisk
f
Fast

Have you had any falls in the past 12 months? (Tick one box)

a
No falls
b
One fall
c
More than one fall
Do you have difficulty with any of the following activities? (One tick for each row)
-

1 - No problem

2 - Mild Problem

3 - Moderate Problem

4 - Severe Problem

Walking
Getting up from sitting
Opening jars that have never been opened
How much have you been troubled by the following sleep problems in the past 3 months?

(One tick for each row)

-

1 - No problem

2 - Mild Problem

3 - Moderate Problem

4 - Severe Problem

Difficulty falling asleep
Difficulty staying asleep
Waking up too early
Not feeling refreshed in the morning
Below is a list of ways you might have felt or behaved – please tell us how often you have felt this way during the past 7 days including today (One tick for each row)
During the past 7 days

1 - Rarely or none of the time (less than one day)

2 - Some or a little of the time (1-2 days)

3 - Occasionally or a moderate amount of the time (3 - 4 days)

4 - Most or all of the time (5-7 days)

I was bothered by things that usually didn’t bother me
I did not feel like eating; my appetite was poor
I felt that I could not shake off feeling low, even with help from my family and/or friends
I felt I was just as good as other people
I had trouble keeping my mind on what I was doing
I felt depressed
I felt that everything I did was an effort
I felt hopeful about the future
I thought my life had been a failure
I felt fearful
My sleep was restless
I was happy
I talked less than usual
I felt lonely
People were unfriendly
I enjoyed life
I had crying spells
I felt sad
I felt that people dislike me
I could not get “going”
On the next two pages we are going to ask you a few questions about the food you eat.
Approximately how many times, over the past 3 months, have you have eaten each of the particular foods found within the table below.

Please complete the table, by circling the number in the appropriate box. Please circle a number on every line.

AVERAGE USE IN PAST 3 MONTHS

0 - Never

1 - Less than once/ month

2 - 1-3 per month

3 - Once a week

4 - 2-4 per week

5 - 5-6 per week

6 - Once a day

7 - 2-3 per day

8 - 4-5 per day

9 - 6+ per day

White bread (one slice)
Brown and wholemeal bread (one slice)
Biscuits eg digestive (one)
Apples (one fruit)
Bananas (one fruit)
Melon, pineapple, kiwi and other tropical fruits (medium serving)
Green salad eg lettuce, cucumber, celery
Garlic – raw and cooked dishes
Marrow and courgettes
Peppers – cooked & fresh
Yogurt (125g pot)
Eggs as boiled, fried, scrambled etc. (one egg)
White fish eg cod, haddock, plaice, sole (not in batter/crumbs)
Oily fish, eg. mackerel, tuna, salmon
Bacon and Gammon
Meat pies, eg. pork pie, pasties, steak & kidney, sausage rolls
Boiled, mashed and jacket potatoes (one egg size potato)
Chips
Pasta eg spaghetti, macaroni

Approximately how many times, over the past 3 months, have you have eaten each of the particular foods found within the table below. FOOD AND AMOUNTS Which is the main spreading fat you have used for example on bread, toast or vegetables? Spreading fat (teaspoon) Please name the spreading fat you use - ... AVERAGE USE IN PAST 3 MONTHS

Please complete the table, by circling the number in the appropriate box. Please circle a number on every line.

0
Never
1
Less than once/ month
2
1-3 per month
3
Once a week
4
2-4 per week
5
5-6 per week
6
Once a day
7
2-3 per day
8
4-5 per day
9
6+ per day
Generic text
Which types of milk have you used regularly in drinks and added to breakfast cereals over the past three months?

In the table below, please write in, on average, how much of each milk type you have consumed per day, over the past 3 months.

Please tick On average, over the past 3 months, how much milk have you consumed per day?

1 - tick

Pints per day

1 - tick

Pints per day
Whole pasteurised or UHT
Semi-skimmed pasteurised (include 1% milks) or UHT
Skimmed pasteurised or UHT
Other (Please specify)
None (go to Q68)
If you do not consume milk please place a tick beside None and continue to Question 68.

Which types of milk have you used regularly in drinks and added to breakfast cereals over the past three months? Other (Please specify)

Other

Have you added sugar to tea and coffee or breakfast cereals in the past 3 months?

a
Yes
b
No
If yes,
qc_68 == a

approximately how many teaspoons of sugar have you added each day? ... teaspoons

How many
Past 12 months

In the past 12 months have you lost more than 10 pounds (4.5 kg) unintentionally (i.e. without dieting or exercise)?

a
Yes
b
No

During the past 12 months, have you had pain in your BACK or NECK for a month or longer that made it difficult or impossible to get washed or dressed or do household chores?

a
No
b
Yes

During the past 12 months, have you had pain in your ARM(S) or SHOULDER(S) for a month or longer that made it difficult or impossible to get washed or dressed or do household chores?

a
No
b
Yes

During the past 12 months, have you had pain in your LEG(S) for a month or longer that made it difficult or impossible to get washed or dressed or do household chores?

a
No
b
Yes

During the past 12 months, how many days have you had off work in total because of problems with your health? (Tick one box)

a
No time
b
Less than 5 days
c
5 to 20 days
d
More than 20 days
e
or Not applicable (not working over this time)

During the past 12 months, how many days have you had off work in total because of pain in your back, neck, arms, shoulders or legs? (Tick one box)

a
No time
b
Less than 5 days
c
5 to 20 days
d
More than 20 days
e
or Not applicable (not working over this time)

During the past 12 months, have you had to cut down, avoid or change what you normally do at work because of health problems? (Tick one box)

a
Yes, a lot
b
Yes, a little
c
No, not at all
d
Not applicable (not working over this time)

Thinking back over the past month, have you had any aches or pains that have lasted for one day or longer? (Tick one box)

a
Yes
b
No
If YES,
qc_77 == a

please shade in the diagrams below where you feel, or have felt, these aches and pains:

Referring to the aches and pains you shaded in the diagram above, have you been aware of these pains for more than three months? (Tick one box)

a
Yes
b
No
c
Not applicable

Has a doctor ever told you that you have osteoarthritis? (Tick one box)

a
Yes
b
No
c
Not sure
You have now finished FORM A.
Please also complete FORM B, and post both forms back in the pre-paid envelope supplied. THANK YOU!
End

heaf_16_fup3

Health & Employment After Fifty (HEAF Study): Follow-up Questionnaire
The answers given on this form are confidential. Replies will only been seen by a small medical research team

Section One: About Yourself and Your Work

Please fill in today’s date
Generic Date
Please fill in your date of birth
Date of birth
What is your current marital status? (Tick one box)
a
Married
b
Single
c
Civil partnership
d
Widowed
e
Divorced
f
Living with a partner

In an average week, roughly how many hours would you spend doing the following activities? (Please answer each question)

Hours per week
Hours in week
Working in a paid job (whether employed or self-employed)
Giving personal care to someone in your home or family
Working in an unpaid job for others outside your home and family (e.g. as a volunteer for a charity)
Doing hobbies

In an average week, and outside any paid jobs that you do, roughly how many hours would you spend doing the following activities? (Please answer each question)

Hours per week
Hours in week
Physical activities sufficient to make you hot or sweaty (e.g. heavy gardening, dancing, cycling, jogging)
Meeting or doing things with friends or relatives who do not live in your home
Which of the following best describes your present work situation? (Tick one box)
a
Employed
b
Self-employed
c
Unemployed
d
Retired
e
Employed off sick
f
Self-employed off sick
Has your employment position changed since we last contacted you about a year ago?
1
I did not have a paid job when you last contacted me, and I do not have a paid job now
2
I have the same main job as when you last contacted me
3
My employment position has changed since you last contacted me.
Is your main job more or less the same as when we last contacted you (i.e. hours worked, tasks involved, support from managers and colleagues)?
a
No
b
Yes
If yes, please move on to Question 29 on page 5
How has it changed?
Generic text
Have you reduced or changed what you do at work because of a health problem? Please describe the health problems and any changes your employer may have made to help
1
No
2
Yes
Generic text
If you have answered questions 7 and 8 and are still in the same main job as when we last contacted you please go to Question 29 on page 5
In the time since we last contacted you, have you left the main job you were doing at that time?
1
No, I did not have a job when last contacted.
2
Yes
When did you leave the job?
Generic Date
Did you leave because of a health problem? (Tick one box)
a
No, not at all
b
Yes, a health problem was the main reason for leaving
c
Yes, a health problem was part of the reason for leaving
what type of problem was it? (Tick all the boxes that apply)
a
A problem with your back, neck, arm, shoulder or leg
b
A mental health problem or stress
c
A problem with your heart or lungs
d
Another type of health problem
e
Not applicable, no health problem
Do you have a new paid job (whether employed or self-employed) since we last contacted you?
a
No
b
Yes
What is your MAIN occupation at the moment? Occupation (e.g. secretary, teacher, builder)
Generic text
and in what industry do you work? Industry (e.g. farming, shipyard, car factory, shoe shop, hospital, insurance office)
Generic text
When did you start this job?
Generic Date
Is your contract of employment permanent or temporary/renewable?
a
Permanent
b
Temporary/renewable
c
Not applicable (self-employed)
Roughly how many people in total work for your employer?
a
Just you
b
2-9
c
10-29
d
30-499
e
500 or more
Does your main job involve rotating or variable shifts?
a
Often
b
Sometimes
c
Rarely/never
Does your main job involve night work (i.e. between 2.00 a.m. and 4.00 a.m.)?
a
Often
b
Sometimes
c
Rarely/never
Is driving part of your main job?
a
Essential to the job
b
A part of the job, but not essential
c
No

In your main job, does an average day at work involve any of the following activities?

-

1 - No

2 - Yes

Kneeling or squatting for longer than 1 hour per day in total
Climbing a ladder
Climbing up and down more than 30 flights of stairs per day
Digging or shovelling
Lifting weights of 10kg (25lbs) or more by hand
Standing or walking for most of the day
Standing or walking for more than 3 hours at a time
Hard physical work that makes you hot or sweaty
Ignoring overtime, does your main job give you a fixed salary, or are you paid according to your output (e.g. the number of tasks you do or things you make)? (Tick one box)
a
Fixed salary
b
Paid by output
In your main job, do you have a choice in deciding what you do, how you do things, or when you do things? (Tick one box)
a
Often
b
Sometimes
c
Rarely/never
Do you have a fixed time when you have to begin work? (Tick one box)
a
All work days
b
Most work days
c
Some work days
d
Never (I choose for myself)
How much holiday are you allowed from your job per year (including Bank Holidays)?a) ... Days or b) ... No fixed limit (Please tick)
Days in year
b
tick
How much holiday do you take each year in your job (including Bank Holidays)? ... days
Days in year
If you fell ill and were off work, how long could you get your normal full pay (excluding bonuses)? (Tick one box)
a
Less than one week
b
1 to 4 weeks
c
1 to 6 months
d
More than 6 months
e
Not sure
If you had a long-term health problem, might you qualify for an ill-health retirement pension (from your employer or insurance)? (Tick one box)
a
Yes
b
No
c
Don’t know
Do you have a zero hours contract?
a
Yes
b
No
When you have difficulties at work, how often do you get help and support from your colleagues, supervisor or manager? (Tick one box)
a
Often
b
Sometimes
c
Rarely/never
d
Not applicable (work alone)
Do you ever lie awake at night worrying about work or angry about work? (Tick one box)
a
Often
b
Sometimes
c
Rarely/never
How satisfied are you with the amount you are paid in your job, all things considered?
a
Very satisfied
b
Satisfied/fairly satisfied
c
Dissatisfied
d
Very dissatisfied
How satisfied are you with your working hours and your work timetable (e.g. start and finish time), all things considered? (Tick one box)
a
Very satisfied
b
Satisfied/fairly satisfied
c
Dissatisfied
d
Very dissatisfied
Does your work give you a feeling of achievement? (Tick one box)
a
Often
b
Sometimes
c
Rarely/never
In your work, do you feel appreciated by others (managers, colleagues, customers etc)?
a
Often
b
Sometimes
c
Rarely/never
Do you have friends at work with whom you also spend time outside work? (Tick one box)
a
Yes
b
No
Is there anyone at work you find very difficult to get on with? (Tick one box)
a
Yes
b
No
Do you ever get criticised unfairly at work? (Tick one box)
a
Often
b
Sometimes
c
Rarely/never
How satisfied have you been with your job as a whole, taking everything into consideration?
a
Very satisfied
b
Satisfied/fairly satisfied
c
Dissatisfied
d
Very dissatisfied
Provided that you stay well, how secure do you feel your job is?
a
Very secure
b
Secure
c
Rather insecure
d
Very insecure
How secure do you feel your job would be if you had an illness that kept you off work for three months or more? (Tick one box)
a
Very secure
b
Secure
c
Rather insecure
d
Very insecure
Currently, how well do you cope with the physical demands of your job? (Tick one box)
a
Easily
b
Just about
c
With some difficulty
d
With great difficulty
e
Not coping
Currently, how well do you cope with the mental demands of your job? (Tick one box)
a
Easily
b
Just about
c
With some difficulty
d
With great difficulty
e
Not coping
Do you expect that you will still be able (physically and mentally) to carry out the same kind of work in two years time? (Tick one box)
a
Yes
b
No
c
Not sure
Does your job involve sitting for most of the day?
a
Yes
b
No

Section Two: Personal Finance

How well do you feel you are managing financially these days? (Tick the box that best applies)
a
Living comfortably
b
Doing alright
c
Just about getting by
d
Finding it difficult to make ends meet
e
Finding it very difficult to make ends meet
Are there things which you used to have, and which you would like to have now, but can no longer afford? (Tick one box)
a
No
b
A few things
c
Many things
Are there things which your friends or family have, that you would like to have but cannot afford? (Tick one box)
a
No
b
A few things
c
Many things

Have you ever received any of the following benefits? (Please tick all that apply)

-

1 - yes

Incapacity benefit
Invalidity benefit
Disability Living Allowance (DLA)
Severe Disablement Allowance
Personal Independence Payment (PIP)
Employment and Support Allowance (ESA)
None of the above
has a benefit ever been stopped as a result of an assessment? (Tick one box)
a
Yes
b
No
c
Not applicable
when was this? (if more than one benefit has been stopped, please record the first time this happened)
Generic Date
Are you currently receiving an ill-health retirement pension?
a
No
b
Yes
If you are already fully retired, please tick this box and move to Section 3 on page 8, starting at Question 57.
1
tick
At what age do you expect to retire fully? ... years old
Age
Do you expect to reduce your paid work before you retire fully? (e.g. by working shorter hours for less pay)? (Tick one box)
a
No
b
Yes
c
Not sure
In an ideal world, at what age would you like to retire fully? a) … years old
Age
1
or never

Section Three: Health

In general would you say your health is? (Tick one box)
a
Excellent
b
Very good
c
Good
d
Fair
e
Poor
How much of the following do you drink per week, on average? Beer, cider, lager ... Pints
How many
How much of the following do you drink per week, on average? Wine, sherry ... Glasses
How many
How much of the following do you drink per week, on average? Spirits, Liqueurs ... measures
How many
Please give your weight Weight ... st ... lbs or ... kg
Stones
Pounds in stone
Kilograms

Below are some statements about feelings and thoughts. Please tick the box in each row that best describes your experience of each over the last 2 weeks (One tick for each row)

-

1 - None of the time

2 - Rarely

3 - Some of the time

4 - Often

5 - All of the time

I’ve been feeling optimistic about the future
I’ve been feeling useful
I’ve been feeling relaxed
I’ve been feeling interested in other people
I’ve had energy to spare
I’ve been dealing with problems well
I’ve been thinking clearly
I’ve been feeling good about myself
I’ve been feeling close to other people
I’ve been feeling confident
I’ve been able to make up my own mind about things
I’ve been feeling loved
I’ve been interested in new things
I’ve been feeling cheerful
Which of the following best describes your walking speed? (Tick one box)
a
Unable to walk
b
Very slow
c
Stroll at an easy pace
d
Normal pace
e
Fairly brisk
f
Fast
Have you had any falls in the past 12 months? (Tick one box)
a
No falls
b
One fall
c
More than one fall

Do you have difficulty with any of the following activities? (One tick for each row)

-

1 - No problem

2 - Mild Problem

3 - Moderate Problem

4 - Severe Problem

Walking
Getting up from sitting
Opening jars that have never been opened

How much have you been troubled by the following sleep problems in the past 3 months?

-

1 - No problem

2 - Mild Problem

3 - Moderate Problem

4 - Severe Problem

Difficulty falling asleep
Difficulty staying asleep
Waking up too early
Not feeling refreshed in the morning

Below is a list of ways you might have felt or behaved – please tell us how often you have felt this way during the past 7 days including today (One tick for each row)

During the past 7 days

1 - Rarely or none of the time (less than one day)

2 - Some or a little of the time (1-2 days)

3 - Occasionally or a moderate amount of the time (3 - 4 days)

4 - Most or all of the time (5-7 days)

I was bothered by things that usually didn’t bother me
I did not feel like eating; my appetite was poor
I felt that I could not shake off feeling low, even with help from my family and/or friends
I felt I was just as good as other people
I had trouble keeping my mind on what I was doing
I felt depressed
I felt that everything I did was an effort
I felt hopeful about the future
I thought my life had been a failure
I felt fearful
My sleep was restless
I was happy
I talked less than usual
I felt lonely
People were unfriendly
I enjoyed life
I had crying spells
I felt sad
I felt that people dislike me
I could not get “going”
On the next two pages we are going to ask you a few questions about the food you eat.

Approximately how many times, over the past 3 months, have you have eaten each of the particular foods found within the table below.

AVERAGE USE IN PAST 3 MONTHS

0 - Never

1 - Less than once/ month

2 - 1-3 per month

3 - Once a week

4 - 2-4 per week

5 - 5-6 per week

6 - Once a day

7 - 2-3 per day

8 - 4-5 per day

9 - 6+ per day

White bread (one slice)
Brown and wholemeal bread (one slice)
Biscuits eg digestive (one)
Apples (one fruit)
Bananas (one fruit)
Melon, pineapple, kiwi and other tropical fruits (medium serving)
Green salad eg lettuce, cucumber, celery
Garlic – raw and cooked dishes
Marrow and courgettes
Peppers – cooked & fresh
Yogurt (125g pot)
Eggs as boiled, fried, scrambled etc. (one egg)
White fish eg cod, haddock, plaice, sole (not in batter/crumbs)
Oily fish, eg. mackerel, tuna, salmon
Bacon and Gammon
Meat pies, eg. pork pie, pasties, steak & kidney, sausage rolls
Boiled, mashed and jacket potatoes (one egg size potato)
Chips
Pasta eg spaghetti, macaroni
Approximately how many times, over the past 3 months, have you have eaten each of the particular foods found within the table below. FOOD AND AMOUNTS Which is the main spreading fat you have used for example on bread, toast or vegetables? Spreading fat (teaspoon) Please name the spreading fat you use - ... AVERAGE USE IN PAST 3 MONTHS
0
Never
1
Less than once/ month
2
1-3 per month
3
Once a week
4
2-4 per week
5
5-6 per week
6
Once a day
7
2-3 per day
8
4-5 per day
9
6+ per day
Generic text

Which types of milk have you used regularly in drinks and added to breakfast cereals over the past three months?

Please tick On average, over the past 3 months, how much milk have you consumed per day?

1 - tick

Pints per day

1 - tick

Pints per day
Whole pasteurised or UHT
Semi-skimmed pasteurised (include 1% milks) or UHT
Skimmed pasteurised or UHT
Other (Please specify)
None (go to Q68)
If you do not consume milk please place a tick beside None and continue to Question 68.
Which types of milk have you used regularly in drinks and added to breakfast cereals over the past three months? Other (Please specify)
Other
Have you added sugar to tea and coffee or breakfast cereals in the past 3 months?
a
Yes
b
No
approximately how many teaspoons of sugar have you added each day? ... teaspoons
How many
Past 12 months
In the past 12 months have you lost more than 10 pounds (4.5 kg) unintentionally (i.e. without dieting or exercise)?
a
Yes
b
No
During the past 12 months, have you had pain in your BACK or NECK for a month or longer that made it difficult or impossible to get washed or dressed or do household chores?
a
No
b
Yes
During the past 12 months, have you had pain in your ARM(S) or SHOULDER(S) for a month or longer that made it difficult or impossible to get washed or dressed or do household chores?
a
No
b
Yes
During the past 12 months, have you had pain in your LEG(S) for a month or longer that made it difficult or impossible to get washed or dressed or do household chores?
a
No
b
Yes
During the past 12 months, how many days have you had off work in total because of problems with your health? (Tick one box)
a
No time
b
Less than 5 days
c
5 to 20 days
d
More than 20 days
e
or Not applicable (not working over this time)
During the past 12 months, how many days have you had off work in total because of pain in your back, neck, arms, shoulders or legs? (Tick one box)
a
No time
b
Less than 5 days
c
5 to 20 days
d
More than 20 days
e
or Not applicable (not working over this time)
During the past 12 months, have you had to cut down, avoid or change what you normally do at work because of health problems? (Tick one box)
a
Yes, a lot
b
Yes, a little
c
No, not at all
d
Not applicable (not working over this time)
Thinking back over the past month, have you had any aches or pains that have lasted for one day or longer? (Tick one box)
a
Yes
b
No
please shade in the diagrams below where you feel, or have felt, these aches and pains:
Referring to the aches and pains you shaded in the diagram above, have you been aware of these pains for more than three months? (Tick one box)
a
Yes
b
No
c
Not applicable
Has a doctor ever told you that you have osteoarthritis? (Tick one box)
a
Yes
b
No
c
Not sure
You have now finished FORM A.
Please also complete FORM B, and post both forms back in the pre-paid envelope supplied. THANK YOU!